Parkview Healthcare

Based on interview, and policy review, the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) plan was developed containing the process the facility will follow to guide the care and services provided to residents and measure improvement. This deficient practice had the potential to not capture the efforts made in measuring the care and services for 112 residents. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program- Governance and Leadership revised March 2020 revealed, Policy Statement The quality assurance and performance improvement program are overseen and implemented by the QAPI committee, which reports its findings, actions and results to the administrator and governing body. During an entrance conference with the facility's Director of Nursing (DON) on 02/17/25 at 9:31 AM and at 4:45PM, a request was made to get the QAPI plan for review. On 02/18/25 at 2:48 PM and 02/20/25 at 11:00AM, a request was made to the Administrator for the QAPI plan. On 02/20/25 at 09:44 AM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure the grievances voiced repeatedly by the resident council were addressed and resolution presented to the council regarding food palatability, staff to resident interactions, pest control, and call light response. These failures had the potential to create feelings of dissatisfaction and helplessness among the eight residents who participated in Resident Council (R96, R2, R48, R88, R87, R109, R106, and R17) out of a census of 112 residents. Findings include: 1. During the group meeting interview on 02/19/25 at 10:00 AM, there was seven participants, R96, R48, R88, R87, R109, R106, and R17. a. Review of R48's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE]. Review of R48's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/10/24 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to protect the resident's right to be free from physical or verbal abuse by another resident for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse. Findings include: 1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety. Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52 was cognitively intact. He did not exhibit mood or behavioral symptoms. Review of R52's Behavior note dated 06/25/24 and located under the Progress Notes tab of the EMR, revealed, [Social Service Director] was notified of altercation between a resident and his/her roommate, both resident and roommate was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and reporting of all alleged violations to the state survey agency (SSA) for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse. Findings include: 1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he/she was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety. Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52 was cognitively intact. Review of R52's Behavior note, dated 06/25/24 and located under the Progress Notes tab of the EMR, revealed, [Social Service Director ] was notified of altercation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to ensure allegations of resident-to-resident abuse were investigated for four residents (Resident (R) 52, R26, R31, and R24) of six residents reviewed for abuse. Findings include: 1. Review of the Medical Diagnosis tab of R52's electronic medical record (EMR) revealed he was admitted on [DATE] with diagnoses of schizophrenia, major depression, and anxiety. Review of R52's significant change of status Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/15/25 and located in the MDS tab of the EMR, revealed the Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R52's cognition was intact. Review of the Medical Diagnoses tab of the EMR revealed R26 was admitted on [DATE] with a diagnosis of vascular dementia. Review of R26's quarterly MDS with an ARD of 01/22/25 and located under the MDS tab in the EMR, revealed the BIMS score of 10 out of 15 which indicated R26 had moderately impaired cognition.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure the electronic medication administration record (MAR) matched the Controlled Drug Administration Record Tablet for three residents (Resident (R)65, R97, and R86) out of a total sample of 27 residents. The deficient practice increased the risk of staff administering narcotic medication that had already been administered to residents which increased the risk of adverse effects. Findings include: 1. Review of R65's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE], with diagnosis of chronic pain syndrome. During an interview on 02/17/25 at 10:18 AM, R65 stated that his/her narcotic medications ran out consistently included: oxycodone (a narcotic pain medication) and buprenorphine (a narcotic pain medication). Review of R65's Clinical Physician Orders located under the Orders tab of the EMR revealed an order dated 11/22/24 for Oxycodone 10 milligrams…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and policy review, the facility failed to properly label insulin pens with resident name and opened date and discard expired insulin pens, keep food, personal items and makeup separate from medications for two of six medication carts. The deficient practice could result in altered effectiveness of the medication, worsening of resident's symptoms, Findings include: 1. Observation on 02/19/25 at 1:27 PM of the nurse's medication cart with Licensed Practical Nurse (LPN)3 on the 100 (East) hall revealed: There were two Humalog insulin pens not labeled with the resident's name. There were five Lantus insulin pens open and not dated. There was one Levemir insulin pen that had an open date of 12/08/24. There was one Lantus vial that had an open date of 12/10/24. LPN3 at the time of the observation the insulin was expired and is to be discarded within 28 days after the date opened. A container of applesauce was found stored in the drawer with nebulizer medications. There was lipstick and makeup found in the top drawer without a name. LPN3 stated at the time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, document review and record review, the facility failed to assure food was palatable and served at appetizing temperatures for 10 of 10 residents (R2, R22, R101, R63, R70, R40, R31, R65, R97 and R94) reviewed for food concerns out of a sample of 27. Additionally, review of Review of Resident Council Meeting Minutes revealed complaints related to food palatability from five of five months of minutes reviewed. Failure to serve palatable and appetizing foods placed all residents residing in the facility at risk for weight loss. Findings include: 1. During meal service on 02/20/25, the [NAME] was observed testing temperatures of the foods on the tray line prior to starting tray service. A check of the log showed temperatures were recorded between 170 and 190 Degrees Fahrenheit (F). A test tray was requested from dietary and on 02/20/25 at 1:28 PM. The last tray cart left the kitchen for east hall residents who ate in their room and included the test tray. After the last trays were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and policy review, the facility failed to inform the 29 residents, R315, R77, R97, R104, R316, R72, R105, R61, R107, R68, R63, R24, R13, R108, R7, R106, R314, R67, R62, R110, R22, R73, R109, R115, R119, R116, and R117, and/or their representatives who signed the binding arbitration agreement out of a census of 112 in writing they were not required to enter into a binding arbitration agreement as a condition of admission. This failure placed these 29 residents at risk of signing the agreement involuntarily. Findings include: Review of the facility's Arbitration Agreement Rider to the admission Contract, provided by the Administrator revealed, The parties agree that any and all disputes arising out of or in any way related to the contract or the Resident's stay at the facility . shall be decided by arbitration in accordance with this Rider. The arbitration proceeding and settlement shall remain confidential . The resident also understands that nothing in this Rider prevents him/her from communicating with federal, state, or local officials . The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and policy review, the facility failed to inform the 29 residents and/or their representatives (Resident (R)315, R77, R97, R104, R316, R72, R105, R61, R107, R68, R63, R24, R13, R108, R7, R106, R314, R67, R62, R110, R22, R73, R109, R115, R119, R116, and R117) who signed the binding arbitration agreement out of a census of 112 in writing of the right to selection of neutral arbitrator agreed upon by both parties. This failure placed these 29 residents at risk of misunderstanding the process for selection of an arbitrator. Findings include: Review of a copy of the facility's Arbitration Agreement Rider to the admission Contract, provided to the survey team by the Administrator, revealed, The parties agree that any and all disputes arising out of or in any way related to the contract or the Resident's stay at the facility . shall be decided by arbitration in accordance with this Rider. The arbitration proceeding and settlement shall remain confidential . The resident also understands that nothing in this Rider prevents him/her from communicating with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure five of five residents (Resident (R) 85, R70, R107, R34, and R95) residents reviewed for immunizations out of a total sample of 27 were assessed for eligibility, educated on the risks and benefits, and offered pneumococcal vaccination. This failure placed all eligible residents who wished to receive the vaccine at risk for contracting pneumonia unnecessarily. Findings include: In an interview on 02/21/25 at 5:21 PM, the Infection Preventionist (IP) stated he/she had just taken over the position about a month ago, and the former Assistant Director of Nursing who no longer worked at the facility had been in charge of the infection prevention and immunization program prior. He/She stated immunizations were documented either on paper in binders he/she kept or in the electronic medical record (EMR). The IP stated he/she was working on getting immunizations caught up, and stated he/she was able to administer influenza and COVID-19…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to maintain a safe and comfortable environment for six rooms (Resident (R) 70, R56, R94, and R65, room [ROOM NUMBER], and room [ROOM NUMBER]) of 32 rooms observed in Initial Pool. Findings include: 1. During an interview on 02/21/25 at 7:08 PM, the Regional Maintenance Consultant (RMC) stated he/she had just been hired to start implementing the necessary corrective measures to ensure a safe, clean, and comfortable environment. The RMC stated he/she did notice issues with walls in disrepair, broken heating vents or light fixtures, and other maintenance issues. The RMC stated the Maintenance Director had been at the facility for about a year and a half and he/she did not know why the issues had not yet been addressed and stated the Maintenance Director needed training on time management and prioritization. The RMC stated the facility had just recently implemented a reporting program through their electronic medical records (EMR) system in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to implement pest control measures to prevent mouse infestation in the facility, which affected four of 27 sampled residents (Resident (R) 76, R2, R22, and R73) and the common areas of the facility. This failure had the potential to cause an increase in rodent activity, creating a potential for spread of infection and dissatisfaction with living arrangements among the residents. Findings include: Review of March 2024 to December 2024 weekly pest control Service Inspection Reports, provided by the facility, revealed ongoing treatment for mice. The reports repeatedly documented the same recommendations for preventing the mice from entering the building. These recommendations included: -Fixing holes in the walls near several heat registers, -Fixing holes by baseboards throughout the facility, -Ensuring kitchen doors were rodent-proofed by eliminating gaps, -Ensuring gap under the front door was eliminated, and -Removing trash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and policy review, the facility failed to ensure residents were allowed to exercise their rights to make choices important to them, the right to privacy, and the rights to have care provided in manner that supported each resident's autonomy. The affected three residents (Resident (R) 31, R22 and R19) in the sample of 27 residents. Findings include: Review of the facility's policy titled, Dignity, revised February 2021, revealed, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings, of self-worth and self-esteem . 1. Review of R19's admission Record, provided by the facility, revealed an admission date of 03/09/23 with diagnoses that included diabetes mellitus, major depressions, and history of transient ischemia attacks. Review of R19's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/23/24 located in the electronic medical record (EMR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review, the facility failed to ensure residents were provided the correct form or provided the form that included the potential additional costs that the resident might have to pay if they chose to continue to receive services, Skilled Nursing Facility Advance Beneficiary Notice, form CMS-10055, for Medicare Part A Services when they were no longer covered or coverage was ending for three of three residents reviewed (Resident (R) 61, R110, and R114). This deficient practice had the potential to allow residents not to be provided the information about what services may not be covered by Medicare for residents to make an informed decision about receiving therapies. Findings include: Review of the facility policy titled, Advance Beneficiary Notices revised [DATE] revealed, Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. 5. The current CMS-approved version of the forms shall be used at the time of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure the assessment accurately reflected weight and significant weight loss for one (Resident (R) 52) of 12 residents reviewed for nutrition. This failure placed R52 at risk of additional unplanned weight loss or malnutrition. Findings include: Review of R52's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE] with diagnoses including: acute kidney failure, chronic kidney disease-stage four with dependence on renal dialysis, hyperkalemia (high potassium), hypomagnesemia (low magnesium), type 1 diabetes mellitus, anemia, and hypertension. Review of R52's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/28/24 indicated his/her weight was 195 pounds (lbs) and he/she had not experienced any significant weight loss or gain. Review of R52's weights found on the Weights and Vitals tab of the EMR revealed on 09/04/24, the resident weighed 193 lbs and on 10/01/24,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) level I screening for mental disorder was completed for one (Resident (R) 36) of 27 residents in the sample. This failure had the potential for R36 to reside in the facility without a determination by the State mental health authority as appropriate for admission. Findings include: Review of R36's Medical Diagnosis tab of the electronic medical record (EMR) revealed he/she was admitted on [DATE] with diagnoses including major depressive disorder, schizoaffective disorder, post-traumatic stress disorder (PTSD), and alcohol abuse and other psychoactive substance abuse with intoxication. He/She did not have a diagnosis of dementia. Review of the Orders tab of the EMR revealed R36 had physician orders which originated on 08/26/24, for olanzapine (an antipsychotic medication), 5 milligrams (mg) at bedtime and 2.5 mg during the day for schizoaffective disorder. Review of R36's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to develop and implement interventions for safety for two (Resident (R) 2 and R32) of two residents reviewed for substance use disorders. Findings include: 1. Review of R2's Medical Diagnosis tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including anxiety, nicotine dependence, post-traumatic stress disorder, alcohol abuse, and bipolar disorder. Review of R2's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/21/24 and located under the MDS tab of the EMR, revealed the Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 was cognitively intact. Review of R2's Behavior note dated 10/16/24 and located in the Progress Notes tab of the EMR revealed, Resident tested positive for fentanyl [potent pain medication] during drug screen on 2 attempts this date. Review of R2's Behavior note dated 10/17/24 and located in the Progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and policy review, the facility failed to ensure three of three portable compressed oxygen cylinders were safely stored in a secure device. The deficient practice had the potential for severe physical harm if the pressurized cylinder was to be knocked over and explode. In addition, the facility failed to ensure respiratory equipment was kept in a clean and sanitary manner for one of three residents (Resident (R) R58) reviewed for oxygen usage in the sample of 27. Failure to provide clean oxygen tubing and oxygen filter increased the risk for respiratory problems related to contaminated equipment. Findings include: 1. Review of the facility's policy titled, Oxygen Safety, revised May 2011 indicated, Store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. Never leave oxygen cylinders free-standing. Review of the undated facility policy titled Oxygen Safety revealed, Policy: It is policy of this facility to provide a safe environment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure pharmacy recommendations were reviewed and signed by the physician for two of five sampled residents (Resident (R)19 and R60). This deficient practice had the potential to allow residents to continue to receive medications with irregularities that the physician has not furnished a rational. Findings include: 1. Review of R19's electronic medical record (EMR) revealed admission Record which indicated the admission date of 03/09/23 with diagnoses major depressions and anxiety. Review of R19's quarterly Minimum Data Set (MDS)located in the EMR under the MDS tab with an assessment reference date (ARD) of 12/23/24 showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognitive ability. Review of R19's Physician Orders located in the EMR under the Orders tab revealed an order dated 07/08/23 for clonazepam oral tablet 1 milligram (mg) by mouth three times a day for anxiety; order dated 06/25/24 for sertraline tablet 25mg give one tablet by mouth one time a day for depression; and order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that one of one resident (R)50) in the sample of 27 revealed the resident's preference for a sandwich to be add to the lunch and dinner meals was not being honored. The failure to ensure that a resident's food preferences were honored could result in the resident loosing weight. Findings include: 1. Review of R50's Medical Diagnosis tab of the EMR revealed he/she was admitted on [DATE] with diagnoses including peripheral vascular disease, heart disease, and amputation of toes. Review of R50's quarterly MDS with an ARD of 02/05/25 and located under the MDS tab of the EMR, revealed the BIMS score of 15 out of 15 which indicated intact cognition. During an interview on 02/17/25 at 10:08 AM, R50 stated he/she was supposed to receive a sandwich with his/her meals, but he/she never received one. He/She explained his/her meal tickets documented he/she was to receive a sandwich with every meal because he/she did not feel like he/she got…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and facility policy, the facility failed to implement infection prevention strategies to prevent cross-contamination during the medication pass for three of five residents (Resident (R) 94, R316, and R18) observed during the medication pass out of a total sample of 27. This failure had the potential to spread infectious diseases to all residents. The facility census was 112 residents. Findings include: Observation on 2/19/25 at 9:13 AM. CMT6 did not sanitize the blood pressure cuff prior to taking R94's blood pressure. Observation on 02/19/25 at 9:30 AM, CMT6 did not sanitize the blood pressure cuff prior to taking R316's blood pressure. Observation on 02/19/25 at 9:41 AM, CMT6 did not sanitize the blood pressure cuff prior to taking R18's blood pressure. During an observation on 02/19/25 at 9:13 AM to 10:05 AM, during medication administration, CMT6 failed to perform handwashing or hand hygiene prior to preparing medications for administration to R18. During an interview on 02/19/25 at 2:27 PM, Registered Nurse (RN) 1 stated blood pressure cuffs…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure one (Resident (R) 32) of one resident review for antibiotic use in the sample of 27 had a duration of antibiotic therapy specified and antibiotic use did not continue without medical necessity. This failure placed R32 at risk of antibiotic resistance or unnecessary adverse effects of the medication. Findings include: Review of R32's Medical Diagnosis tab of the EMR revealed he was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease. Review of R32's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/10/25 and located in the MDS tab of the EMR revealed he received antibiotics. Review of R32's EMR under the Orders tab revealed a physician's order dated 01/10/24 to give one drop of Ofloxacin Ophthalmic Solution 0.3 % (antibiotic eye drops) in the left eye four times a day for cataract surgery. The order did not include a stop date. Review of R32's Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide a written discharge notice to one sampled resident (Resident #2) and/or his/her guardian upon emergency discharge from the facility out of five sampled residents. The facility census was 101 residents. Review of the facility's policy titled Transfer or Discharge Notice dated March 2021 showed residents and/or representatives were notified in writing, and in a language and format they understood, at least 30 days prior to a transfer or discharge. 1. Review of Resident #2's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/9/24 showed the resident was discharged on 10/9/24 and the resident's discharge was unplanned. Review of a nurse's note dated 10/9/24 at 3:14 P.M. showed the resident had called Emergency Medical Services (EMS) on himself/herself and was transported to a local hospital. Review of a nurse's note dated 10/9/24 at 6:30 P.M. showed: -The Director of Nursing (DON) had given verbal emergency discharge notice to Guardian A.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to permit one sampled resident (Resident #2) for re-admission to the facility out of five sampled residents. The facility census was 101 residents. Review of the facility's policy titled Bed-Hold and Returns dated March 2022 showed: -A resident would be permitted to return to an available bed in the location of the facility that he or she previously resided in. -If there was not an available bed in that part, the resident would be given the option to take the available bed in another distinct part of the facility and return to the previous distinct part when a bed were to become available. 1. Review of Resident #2's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/9/24 showed the resident was discharged on 10/9/24 and his/her return was not anticipated. Review of a nurse's note dated 10/9/24 at 3:14 P.M. showed the resident had called Emergency Medical Services (EMS) on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent the physical abuse of three sampled residents (Resident #4, #5 and #6). On 11/2/24 Family Member A entered the facility visibly and verbally upset stating to call 911 as he/she had been robbed. Receptionist A let Family Member A into the building. Family Member A began down the hall. Certified Nurse Aide (CNA) A followed Family Member A to ask why 911 should be called. Before CNA A could get an answer, Family Member A entered Resident #1 and Resident #2's room. Family Member A then went to Resident #1's side of the room struck Resident #3 and Resident #1 in the face and mouth area. Then Family Member A went to the bedside of Resident #2 where the resident was sleeping and struck Resident #2 in the face. Family Member A struck all three residents in the face or mouth area causing all three of them to have minor lacerations and bruising documented in their chart where first aid was provided out of seven sampled residents. The facility census was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to take corrective action which included physician notification, staff education, staff training and or staff in-services after physical abuse of three sampled residents (Resident #4, #5 and #6) out of seven sampled residents. The facility census was 105 residents. Review of the facility Abuse, Neglect, Exploitation or Misappropriation Prevention Program Policy dated 4/2024 showed: -Protect residents from abuse by anyone including visitors. -Provide orientation and training programs that include topics such as abuse prevention, identification and reporting abuse. -Establish and implement a Quality Assurance Performance Improvement (QAPI review and analysis of reports, allegations or findings of abuse). Review of the facility Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation Policy dated 4/2024 showed: -The individual conducting the investigation as a minimum includes: --Interviews with the resident's attending physician as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the guardian, emergency contact and/or physician for one sampled resident (Resident #7) when on 10/30/24 the resident did not return to facility out of seven sampled residents. The facility census was 105 residents. Review of the facility Wandering and Elopement Policy dated 3/2019 showed: -If a resident is missing, initiate the elopement/missing resident emergency procedure. -Determine if the resident is out on an authorized leave or pass. -If the resident was not authorized to leave, initiate a search of the building and premises. -If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies. Review of the facility Leave of Absence Policy dated 4/1/22 showed: -Leave of Absence (LOA) defined as leaving the facility with the appropriate authorization and notification. -A resident who is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain the call light system which resulted in one sampled resident's (Resident #2) call light not being answered for approximately 20 minutes out of four sampled residents. The facility census was 105 residents. Review of the facility Supporting Activities of Daily Living policy dated 3/2018 showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility Answering the Call Light policy dated 3/2021 showed: -The purpose of this procedure is to ensure timely responses to the resident's requests and needs. -When answering from the call light station, turn off the signal light. -Identify yourself and politely respond to the resident by his/her name,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #3) dignity was maintained when on 9/30/24 Certified Nursing Aide (CNA) B pulled the resident's pants down exposing his/her buttocks to other bystanders out of four sampled residents. The facility census was 105 residents. Review of the facility's Dignity policy dated 2/2021 showed: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. -The facility culture support dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. -This begins with the initial admission and continues throughout the resident's facility stay. -Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. -Demeaning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate weight management for two sampled residents (Resident #8 and Resident #10), who had Percutaneous Endoscopic Gastrostomy (PEG) tubes (a tube that is passed into a person through the abdominal wall, commonly used to provide a means of feeding when oral intake is not adequate), with weight discrepancies out of 10 sampled residents. The facility census was 101 residents. Review of the facility's policy titled Weight Assessment and Intervention dated March 2022 showed: -Residents are weighed upon admission and at intervals established by the interdisciplinary team. -Any weight change of five percent or more since the last weight assessment is retaken the next day for confirmation. -If the weight is verified, nursing will immediately notify the dietician in writing. -Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time. 1. Review of Resident #8's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to obtain physician's orders to ensure the intake of tube feeding and fluids was completed, failed to ensure the flush bag was dated and labeled, and failed to ensure the tube feeding bag and flush bag were changed every 24 hours, for one sampled resident (Resident #10) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube that is passed into a person through the abdominal wall, commonly used to provide a means of feeding when oral intake is not adequate) out of 10 sampled residents. The facility census was 101 residents. Review of the facility's policy titled Enteral (passing through the intestine) Feeding via Continuous Pump dated November 2018 showed: -In preparation staff would need to verify that there is a physician's order for this procedure. -The person performing this procedure should record the following information: --The date and time the procedure was performed. --Verification of tube placement. --Amount and type of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the call light system was operable and within reach for one sampled resident (Resident #1), who was bedbound and needed total assistance from staff for care, out of 10 sampled residents. The facility census was 101 residents. Review of the facility's Call light policy and procedure dated March 2021, showed: -The purpose was to ensure timely responses to the resident's requests and needs. -Be sure the call light is plugged in and functioning at all times. -When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. -Some residents may not be able to use their call light. Be sure you check these residents frequently. 1. Review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses of quadriplegia (a form of paralysis that affects all four limbs, plus the torso), stroke (when blood flow to the brain is blocked or there is sudden bleeding in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to keep the kitchen walk-in refrigerator floor clean; to maintain sanitary utensils and food preparation equipment; to keep trash dumpster's closed; to change the deep fryer oil in a timely manner; failed to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards; failed to separate damaged foodstuff; to store food within acceptable temperature parameters; and to ensure the proper refrigeration of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 105 residents with a licensed capacity for 120 residents at the time of the survey. 1. Record review of an open dietary binder on the table outside the Dietary Manager office, showed Service Line Checklist forms for 4/10/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to meet all the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility; the facility failed to follow their policy to complete testing to screen new employees and residents for tuberculosis (TB- a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for ten out of ten sampled new employees and for five out of five residents (Residents #35,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to be adequately equipped with a complete, functioning call light system throughout the facility to ensure the ability to meet the residents' needs in a timely manner. This deficient practice had the potential to affect all residents who resided in the facility. The facility census was 105 residents with a licensed capacity for 120 residents at the time of the survey. Record review of the facility's emergency preparedness plan in a binder entitled Emergency Operations Plan, obtained from the west nurse station and last revised on 1/7/22, on page #30 with the heading Power Outage, showed there was no policy or procedural plan for an alternate method (for example, bells, whistles, or flashlights) for residents to contact staff to have their needs met in the event of a power outage to the building. 1. Observations during the facility non-resident room inspections with the Administrator and Director of Maintenance (DOM) on 4/18/23 between 11:01…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) was completed and available for three sampled residents (Resident #79, #18, #64 ) out of 21 sampled residents. The facility census was 105 residents. The facility s PASRR Policy was requested several times and one was not provided by time of exit. 1. Record review of resident #79's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/20/23, showed: -The resident was admitted to the facility on [DATE]. -The resident scored a 15 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents were offered or provided as needed showers for three sampled residents (Resident #23, #304, and #204), and to return to a resident's room to assist them after turning out the call light for one sampled resident (Resident #23), out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Shower or Tub Bath, dated February 2018 showed: -Staff was to document the date and time the shower was performed. -Document the name and title of the individual who performed the shower. -Document all assessment data obtained during the shower. -Document how the resident tolerated the shower. -If the resident refused the shower, the reason why and the interventions taken. -Document the signature and title of the person recording the data. -Staff was to notify the supervisor if the resident refuses the shower. -Staff was to notify the physician of any skin areas that may nerd to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The facility maintained a census of greater than 60 residents and this deficiency had the potential to affect all residents. The facility census was 105 residents. The facility policy for staffing of RN coverage for eight consecutive hours per days was requested and was not received by the end of the survey. 1. Record review of the worked staffing sheets on 4/24/23 at 11:31 A.M., showed there was no RN scheduled for eight consecutive hours for the weekend of Friday 4/14/23; Saturday 4/15/23; or Sunday 4/16/23. During an interview on 4/21/23 at 6:04 A.M., Licensed Practical Nurse (LPN) E said: -He/she worked the night shift 6:00 P.M., to 6:00 A.M. -Sometimes there was an RN working the night shift. -There should be an RN working on the day shift. -The Director of Nursing (DON) was an RN and he/she worked day shift. During an interview on 4/21/23 at 6:46 A.M., LPN D said: -The DON was an RN and was in the facility during the weekdays. -The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the narcotic count sheet was signed by both the on-coming and the off-going nurses to verify the correct count of narcotics. The facility census was 105 residents. Record review of the facility's Controlled Substance policy dated April 2019 showed: -The facility complies with all laws, regulations and other requirements related to the handling, storage, disposal, and documentation of controlled medications. -Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. -Controlled medications are counted at the end of each shift. -The nurse coming on duty and the nurse going off duty determine the count together. -Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing (DON) services immediately. 1. Record review on 4/21/23 at 6:47 A.M., of the facility's [NAME] Nurses Station Narcotic and Hypnotic Inventory Sheet in the green narcotic book for the time period of 4/9/23 through 4/21/23 showed the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain Drug Regimen Review (DRR) reports and failed to ensure the reports were acted upon for three sampled residents (Residents #12, #24 and #35) out of five residents sampled for medication review. The facility census was 105 residents. Record review of the facility's Medication and Prescribing - Clinical Protocol policy dated as revised April 2018 showed: -The staff and physician would periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications. -There were no instructions regarding the completion of the DRR reports and acting upon them. 1. Record review of Resident #12's care plan dated as admission date 2/7/22 showed the resident: -Was at risk for abnormal bleeding due to taking blood thinning medication. -Had a diagnosis of diabetes (a deficiency or complete lack of insulin secretion in the pancreas…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the medication carts were locked when the nursing staff was not within sight of the cart; to ensure there were not loose pills in the medication cart drawers; and to ensure cleaning products were not in the same drawer as the residents' medications. The facility census was 105 residents. Record review of the facility's policy, Storage of Medications, dated November 2020 showed: -The facility stores all drugs and biologicals in a safe, secure, and orderly manner. -Drugs and biologicals used in the facility were stored in locked compartments. -Only persons authorized to prepare and administer medications were to have access to locked medications. -The nursing staff was responsible for maintaining medication storage in a clean, safe and sanitary manner. -Compartments (including but not limited to drawers, cabinets, rooms, refrigerator, carts, and boxes) containing drugs and biologicals were locked when not in use. -Unlocked medication carts were not left unattended. 1. Continuous observation on 4/17/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure two sampled residents (Resident #35 and #58,) out of five residents sampled for vaccination review were offered the influenza (flu) vaccine and three sampled residents (Resident #35 #58, and #88) were offered a pneumococcal (pneumonia) vaccine. The facility census was 105 residents. Record review of the facility's flu vaccine policy dated March 2022 showed: -All residents who had no medical contraindications to the vaccine would be offered the flu vaccine annually. -The facility would provide pertinent information about the significant risks and benefits of vaccines to residents. -Between October 1st and March 31st each year, the flu vaccine would be offered to residents unless the vaccine was medically contraindicated or the resident was already immunized. -Any refusal of a vaccine by a resident would be charted in their medical record. Record review of the facility's pneumonia vaccine policy dated March 2022 showed: -Prior to or upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide 12 hours of training/in-services to include behavior & dementia training, abuse prevention, resident rights, care of the cognitively impaired resident, and training areas of weakness as determined in the Nurse aides' performance reviews for five out of five Certified Nursing Assistants (CNA). This had the potential to affect all residents. The facility census was 105 residents. The facility policy for staffing in-services and training was requested and was not received by the end of the survey. 1. Record review of the inservice/trainings dated April 2022 to April 2023 that were provided showed: -Abuse Policy presented by the Regional Social Services (RSS) dated 2/14/23 to all department heads, then the department heads in-serviced their department staff. -Handwashing on 4/20/23 did not show who presented the in-service. It showed as qualifications a Registered Nurse (RN). -Infection Control covering Carbapenem-Resistant Acinetobacter Baumannii (CRAB- bacteria found in environment, especially in soil and water can…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat the residents with dignity by not ensuring two sampled residents, (Resident #23 and #72) genitals were covered up during cares and their Foley catheter bags were in a dignity bag when the residents were outside of their rooms out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Dignity, dated February 2021 showed: -Residents were to be treated with dignity and respect at all times. -Staff was to promote, maintain, and protect residents privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Record review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Acquired absence of other parts of urinary tract (surgical removal of part of the urinary system resulting in person having a urostomy tube - a tube that helps you pass urine when your bladder is not working correctly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Notice of Medicare Provider Non-Coverage (NOMNC) ((Centers for Medicare and Medicaid Services (CMS) form CMS-10123) was provided to the resident or their representative for one sampled resident (Resident #82) and to ensure a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form (CMS)-10055) was provided to the resident or their representative for two sampled residents (Resident #82 and #21) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 105 residents. Record review of the undated Form Instructions for the NOMNC CMS-10123 form showed the NOMNC must be delivered at least two calendar days before Medicare coverage services end. Record review of the CMS memo (S&C-09-20), dated 1/9/09, showed: -The NOMNC, form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide notification to the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of the 30-day discharge notices for two sampled residents (Resident #11 and #43) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy on discharging the resident dated as revised December 2016 showed the policy did not address 30-day discharge notices or notifying the Ombudsman of 30-day discharge notices. Record review of the facility's undated 30-Day Notice policy showed the policy did not address notifying the Ombudsman of 30-day discharge notices. 1. Record review of Resident #11's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 1/23/23 showed: -The resident was cognitively intact. -The resident ranged from being independent to requiring supervision with all activities of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (document that specified health care and support needs and outlines how the facility met resident requirements) that included needs, goals, outcomes and preferences for one sampled resident (Resident #26) for use of oxygen and one sampled resident (Resident #44) for bowel and bladder routine out of 21 sampled residents. This practice had the potential to effect all residents. The facility census was 105 residents. Record review of the facility's Care Plans, Comprehensive Person-Centered Policy, dated, March 2022, showed: -A comprehensive, Person Centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure there were written parameters for when the staff should notify the physician and what to do when a resident's blood sugar was too high or too low for two sampled residents, (Resident #35 and Resident #88) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Nursing Care of the Older Adult with Diabetes Mellitus (diabetes - a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), dated November 2020 showed: -Use a glucometer (a small device that measures how much sugar is in a person's blood sample) for capillary blood sampling to measure correct blood glucose levels. -The target range for healthy older adults was considered 90 - 130 milligrams (mg)/deciliter (dl) (fasting - a person who has not eaten overnight). -The provider would order the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to have in place measures to effectively communicate with one sampled resident (Resident #88) whom English was not his/her primary language and did not provide activities for him/her in Spanish (his/her primary language) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Translation and /or Interpretation of Facility Services dated November 2020 showed: -The facility's language access program would ensure that individuals with Limited English Proficiency (LEP) shall have meaningful access to information and services provided by the facility. -When encountering LEP individuals, staff members would conduct the initial language assessment (e.g., I speak Cards and notify the staff person in charge of the language access program. -Written translation of vital information was available in the following languages at this time: -Policy was blank. -Vital information included the following:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Urinalysis (a test of your urine to check for infection, kidney problems, or diabetes) after a physician ordered the test for one sampled resident (Resident #88) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Principles of Laboratory Specimen Collection, dated 4/1/22 showed: -A specimen collection was performed as ordered by a physician. -Contact the Unit Supervisor for questions or concerns regarding specimen collection. -Document in the progress notes any abnormalities associated with the collection process. 1. Record review of Resident #88's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Diabetes (a group of diseases that result in too much sugar in the blood). -Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Record review of the resident's quarterly Minimum Data Set (MDS - a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure oxygen tubing and the oxygen humidifier were stored in a sanitary condition; and to change out the oxygen tubing per physicians' order for two sampled residents (Resident #18 and #64) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's policy, Oxygen Administration, dated 2022 showed: -Change the oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. -Change humidifier bottle when empty, every 72 hours, or per facility policy, or as recommended by the manufacturer. -Use only sterile water for humidification. -Change nebulizer tubing and delivery device every 72 hours or per facility policy and as needed if they become soiled or contaminated. -Keep delivery devices covered in plastic bag when not in use. 1. Record review of Resident #18's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor for side effects of psychotropic (a type of psychiatric medication which was available on prescription to treat psychosis) medications for one sampled resident (Resident #26) out of 21 sampled residents. The facility census was 105 residents. Record review of the facility's Medication Utilization and Prescribing - Clinical Protocol policy, dated April, 2018, showed: -The physician and staff will identify situations in which a resident took medications associated with potentially significant medication-related problems such as allergies, drug to drug interactions drug-food interactions and adverse drug reactions. -The physician and staff will identify significant factors that may affect medication effectiveness and medication -related problems. -The staff and physician will identify and address unexpected, unintended, undesirable or excessive responses to medication based on the severity of underlying conditions, the seriousness of any adverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain physician ordered labs and/or maintain lab results for two sampled residents (Resident #12 and #35) out of 21 sampled residents. The facility census was 105 residents. A policy regarding following physician's orders for labs was requested but not received. During an interview on 44/26/23 at 2:27 P.M., the Administrator said if a policy wasn't provided that was requested that they did not have it or it was in the computer and they did not find it. 1. Record review of Resident #12's care plan for the admission date of 2/7/22 showed the resident had a diagnosis of Convulsions (a hyperexcitation of neurons in the brain leading to a sudden, violent involuntary series of contractions of a group of muscles). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/25/23 showed the following staff assessment of the resident: -Had short and long-term memory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based interview and record review, the facility failed to establish and maintain competencies and skill sets of facility nursing staff for four out four sampled nurses. The facility census was 62 residents. 1. Record review of four Licensed Nurses employment files on 1/19/21 showed no competencies sign offs could not be produced for verification. During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said: -No competencies could be found for the nursing staff. -He/She started working for the facility in November 2020. -He/She had not provided any competencies or skills check offs since he/she started working for the facility. -He/She could not locate any nursing competencies or skills check offs prior to November 2020. -Training was poor prior to him/her working for the facility, and he/she had just started getting a training program developed. During an interview on 1/19/21 at 11:57 A.M., the Administrator said: -Nursing managers were responsible for ensuring competencies were done. -He/She would expect competencies or skills check offs for all staff.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to have a system in place to ensure a Certified Nursing Assistant (CNA's) received the required 12 hours in-service education based on performance reviews annually for six CNAs out of six sampled. The facility census was 62 residents. 1. Record review on 1/19/21 of six CNAs employment file showed the required 12 hours in-service education hours competencies and/or skills sign offs could not be produced for verification. During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said: -The required 12 hours of CNA in-service education records could not be produced for verification. -He/She started in working for the facility in November 2020. -He/She could not find documentation of any CNA inservice education or skills check-offs prior to November 2020. -He/She had not provided any CNA inservice education or skills check offs since November 2020. -Training was poor prior to him/her coming to the facility, and he/she had just started getting a training program developed. During an interview on 1/19/21 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide 12 hours of in-service training for the licensed nurses on dementia and behavioral health needs for four licensed nurses of four sampled. The facility census was 62 residents. 1. Record review of four Licensed Nurses employment file showed the required 12 hours of in-service training on dementia and behavioral health needs verification could not be produced. During an interview on 1/19/21 at 11:24 A.M., the Social Services Assistant (SSA) said: -He/She started working for the facility in November 2020. -He/She had not provided the required 12 hours in-service training on dementia and behavioral health needs for the nursing staff since he/she started working for the facility. -He/She could not locate any in-service training verification on dementia and behavioral health needs prior to November 2020. -Training was poor prior to him/her working for the facility, and he/she had just started getting a training program developed. During an interview on 1/19/21 at 11:57 A.M., the Administrator: -There should be the 12…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 62 residents. Record review of the facility's Inventory Control of Controlled Substances policy dated 11/28/12 and revised on 11/26/17 showed: -Staff were to always participate in the counting of the controlled substances at the beginning and ending of your shift. -Have partner to assist in the count. -Sign name, time and date of completed count. 1. Record review of the facility's Controlled Drug Count sheet dated 11/9/20 - 11/20/20 showed: -The document did not identify which hall the narcotic count sheet was for. -Five out of 26 opportunities were not signed by either the oncoming or off going staff. Record review of the facility's Controlled Drug Count sheet dated 11/21/20 - 12/3/20 showed: -The document did not identify which hall the narcotic count sheet was for. -Two out of 26 opportunities were not signed by either the oncoming or off going staff. Record review of the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Observation on 1/14/21 at 6:30 A.M., showed: -The Human Resource (HR) Director entered the facility through the double doors from the outside into the foyer. -He/She stood in line waiting to be screened for signs or symptoms of COVID. -There was a receptionist at the desk who was screening people. -There were new surgical masks on the receptionist's desk. -The HR Director stood in the foyer for more than ten minutes without a mask on. -There was one male resident sitting in a chair in the foyer looking out the doors. -The HR Director went into his/her office which was located directly behind the receptionist's desk without a mask on. Observation on 1/15/21 at 8:15 A.M., showed: -CMT A walking down the hall between the East and [NAME] Halls without his/her mask pulled up over his/her nose and mouth. -His/Her mask was down around his/her neck. -He/She was within three feet of a resident. -He/She talked to the resident for six minutes. -The resident was wearing a facemask correctly. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow facility policies and procedures for checking the employee disqualification listing (EDL) and completing the Nurse Aide Registry Check within a timely manner and in accordance with state requirements prior to employing eight of ten employees sampled for the EDL screening and five of ten employees sampled for the Nurse Aide Registry screening. The facility census was 62 residents. Record review of the facility's Abuse Prevention and Reporting revised on 12/10/18, showed regarding pre-employment screening of potential employees: -The facility will not knowingly employ any individual convicted of resident abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. -This facility will not knowingly hire any staff with a disciplinary action in effect against their license by a state licensing body that results from a finding of abuse, neglect, exploitation, mistreatment or misappropriation of resident property. -All potential employees will be screened for a history of abuse, neglect, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure pharmacy Drug Regimen Reviews (DRR) were completed and in the resident's medical record monthly and failed to ensure the resident's physician responded to pharmacy recommendations and the response were documented in the resident's medical record for five sampled residents (Resident #42, #13, #41, #5, and #6) out of 19 sampled residents. The facility census was 62 residents. Record review of the facility's policy titled Pharmacist Medication Review dated 11/28/17 showed: -The Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once per calendar month for each resident residing in certified areas of skilled long term care facility. -The consultant Pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist. Federally mandated standards of care as well as other applicable standards serve as the basis for review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure inhalers and medication vials were dated when opened; failed to ensure expired medications were removed from the medication delivery system; and failed to ensure medications carts are locked and not left unattended by staff when they were unlocked. The facility census was 62 residents. Record review of facilities Medication Storage policy dated 10/1/15 revised 7/2/19 showed: -Facility should ensure that all medications and biologicals, including treatment items, were securely stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors. -Once any medication or biological package was opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when medication had a shortened expiration date once opened. -Facility should ensure that medications and biologicals that: (1) have an expired date on the label, (2) have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow pre-prepared menus to ensure they met the nutritional needs of residents in accordance with established national guidelines, and failed to have a basic ingredient in stock that is called for in many recipes. These deficient practices potentially affected all residents who ate food from the kitchen. The facility's census was 62 residents with a licensed capacity for 120 residents. Record review of the undated Week at a Glance menus for weeks 1 through 4, provided by the DM, showed a variety of meals that met the nutritional needs of residents in accordance with established national guidelines. The lunch meal for week 2 that was supposed to be served was listed as chili mac with buttered peas and peaches with whipped topping. 1. Observations on 1/11/21 at 9:30 A.M. of the lunch meal preparation showed: -The Day [NAME] preparing potato and hamburger casserole, mixed vegetables, and bread. -No recipes were out and being followed during meal preparation. -It could not be determined if any ingredients were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain sanitary food serving utensils and preparation equipment; failed to ensure plastic cutting boards were in good condition to avoid food safety hazards; failed to separate damaged food stuffs; and failed to keep a ceiling vent and floor fan free of lint to prevent food contamination. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 62 residents with a licensed capacity for 120. 1. Observations during the kitchen inspection on 1/11/21 between 8:51 A.M. and 1:15 P.M. showed the following: -A microwave had food splatters on the interior walls, top, and inside of door. -A toaster had an abundance of crumbs in the bottom. -A white cutting board was deeply scored to the point of plastic bits hanging off it. -A white handled spatula had dark brown streaks of an unknown substance dried and peeling off the metal blade. -On a can dispenser rack in the Dry Storage room there was a 6.61 pound (lb) can of mandarin oranges with a dent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to follow standard trash and garbage disposal practices to mitigate the presence of common household pests (for example, bed bugs, lice, roaches, ants, mosquitoes, flies/gnats, mice, and/or rats), and failed to maintain an effective pest control program with measures to eradicate those pests when present. The facility's census was 62 residents with a licensed capacity for 120 residents. 1. Observations during the dining room and kitchen inspections on 1/11/21 between 8:51 A.M. and 2:10 P.M. showed the following: -A roach was on the floor of the southeast dining room doorway to the Main Dining room and another one on the room's west wall. -Gnats were hovering about a full trash can in the southeast dining room by the Kitchen double doors and another one by the room's west wall outlet. -Two roaches were on the floor of the Main Dining room by a wall partition and another one was on top of the trash in the full white trash can by the single kitchen door. -In…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident's Foley catheter (a sterile tube placed in the bladder to drain urine) was in a dignity bag (a covering that can not be seen through that hides the urine of a Foley catheter) while the resident was in a public area and by not ensuring a resident was provided privacy during cares for one sampled resident, (Resident #37) out of 19 sampled residents. The facility census was 62 residents. Record review of the facility's Dignity policy dated 11/28/12 with a revision date 4/23/18 showed: -The facility shall promote care for the residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. -The facility shall consider the resident's life style and personal choices identified through the assessment process to obtain a picture or his or her individual needs and preferences. -The staff shall carry out activities in a manner which assists…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a thorough investigation of a Resident to Resident altercation for one sampled resident (Resident #38) who was at risk for potential resident to resident abuse, and failed to thoroughly investigate an allegation of misappropriation of resident property for one closed record resident (Resident #101) out of 19 sampled residents and seven closed record reviews. The facility census was 62 residents. Record review of the facility's undated Incident/Accident Reports Policy showed: -Policy: The Incident/Accident Report should be completed for all unexplained bruises or abrasions, all accidents or incidents where there was injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors, or others, and resident-to-resident altercations. -Procedure: --An 'incident' was defined as any happening, not consistent with the routine operation of the facility, that did not result in bodily or property damage. --An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide a resident with a discharge notice with the right to appeal upon discharge from the facility, failed to ensure the resident was provided with a discharge plan, failed to allow the resident to return to the facility after his/her improper discharge, failed to notify the resident and family in writing the reason of the transfer to the hospital, and failed to notify the Ombudsman of the resident's discharge from the facility for one closed record resident (Resident #1) and one sampled resident (Resident#37) out of 19 sampled residents and seven closed records. The facility census was 62 residents. Record review of the facility's undated Discharge/Transfer of Resident policy showed: -The purpose was to provide safe departure from the facility and to provide for continuity of care and treatment. -Explain the discharge procedure to the resident and family. -An attending physician's order was required to discharge. -Inform all departments of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Bed Hold notification was provided to three sampled residents (Resident #42, #1, and # 37) or their responsible party for signature, upon discharge to the hospital out of 19 sampled residents and seven closed records. The facility census was 62 residents. Record review of the facility's Bed Hold Policy, revised on 9/16/17, showed the purpose was to ensure that the residents and/or resident representative are notified of the facility bed hold policy and conditions for return to facility upon admission and at the time of a transfer from the facility. The guideline showed the facility's bed hold policy applied to all residents. It showed: -The bed hold policy will be given to the resident and/or resident representative upon admission to the facility, at the time of transfer from the facility and if the bed hold policy under the state plan or the facility's policy were to change. -In cases of emergency transfer, notice at the time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility staff failed to ensure accurate documentation of the use of a Continuous Positive Airway Pressure (CPAP - a method of noninvasive ventilation assisted by a flow of air delivered at a constant pressure throughout the respiratory cycle); failed to obtain a physician's order for a continuous blood glucose monitor for one sampled resident (Resident #13); failed to accurately transcribe physician's orders to include the proper use or diagnosis for a blood pressure medication, for one sampled resident (Resident #7); and failed to ensure a resident had an appointment with a psychiatrist in a timely manner and failed to obtain a physician's order when sending a resident to the hospital for one sampled resident (Resident #37) out of 19 sampled residents. The facility census was 62 residents. Record review of internet reference guide from Mircomedex Drug Reference for Lisinopril (a prescription medication used to treat high blood pressure and heart failure)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a written discharge summary and coordinate discharge planning with the resident's legal guardian for one closed record resident (Resident #107) out of 19 sampled residents, and seven closed record reviews. The facility census was 62 residents. Record review of the facility's undated Discharge/Transfer of Resident policy showed: -Purpose: to provide safe departure from the facility, and to provide for continuity of care and treatment. -Explain the discharge procedure to the resident and family. -Provide additional health education or medication instruction information for the resident or family as indicated in lay terminology. -Ongoing resident/family conferences should address health education and potential discharge planning needs. -Initiate measures for follow-up care as indicated (Social Services, Home Health Care, etc.). -Document discharge summary. Include notes on specific instructions given (medications, dressings, etc.) to resident and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review of Resident's #6 Facesheet showed he/she was admitted to the facility on [DATE] with following diagnosis: -Acquired absence of left leg below the knee. -Peripheral vascular disease (PVD - inadequate flow of blood to the extremities). -Essential hypertension (HTN- high blood pressure). Record review of the facility's Skin Condition Assessment & Monitoring- Pressure and Non-Pressure, dated 11/28/12 and revised on 6/8/18, showed: -Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least weekly by licensed nurse and documented in the resident's clinical record. -Non-pressure skin conditions (bruises/contusions, abrasions, lacerations, rashes, skin tears, surgical wounds, etc.) will be assessed for healing progress and signs of complications or infection weekly. -A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent accidents not ensuring a resident did not have smoking materials in his/her room for one sampled resident (Residents #46), failed to thoroughly document falls and complete a comprehensive fall investigation (which described/documented the resident's fall, interventions that were in place prior to the fall, immediate response to the fall, post fall interventions, notification of the resident's physician and responsible party, and analysis of the possible cause of the resident's fall) for one sampled resident (Residents #59) and one closed record resident (Resident #103) out of 19 sampled residents, and seven closed record reviews. The facility census was 62 residents. Record review of the facility's Fall Prevention Program policy revised 11/21/17 showed: -A Fall Risk Assessment will be performed at least quarterly and with each significant change in mental or functional condition, and after any fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident receiving dialysis (the process of removing blood from an artery (as of a kidney patient), purifying it by dialysis, adding vital substances, and returning it to a vein) had a valid physician's order indicating where and when the resident was to go for dialysis treatment and obtain orders directing staff to monitor the resident's dialysis central venous catheter (CVC - a flexible, long, plastic, Y-shaped tube that is threaded through your skin into a central vein in your neck, chest or groin - a connection between a vein and artery to provide access for dialysis treatment) for one sampled resident (Resident #34) out of 19 sampled residents. The facility census was 62 residents. Record review of the Dialysis Monitoring and Observation policy dated 11/28/12 revised 2/13/18 showed: -If the resident had a catheter for dialysis, the nurse will assess the catheter site for any signs of drainage and condition of the dressing to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a resident was free from unnecessary psychotropic medications for one sampled resident (Resident #13) out of 19 sampled residents. The facility census was 62 residents. Record review of the Pharmacist Medication Review policy dated 11/28/17 showed the Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once per calendar month for each resident residing in certified areas of skilled long term care facility. -The consultant Pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist. Federally mandated standards of care as well as other applicable standards serve as the basis for review to ensure that a resident's medications are promoting or maintaining the resident's highest level of function in congruence with the resident's therapeutic goals and to identify clinically significant risks and/or adverse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review of Resident #42's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including urinary tract infection, pain, diabetes, dementia without behavioral disturbance, high blood pressure, anxiety disorder, obesity, vitamin deficiency, depression and other specified disorders of adult personality and behavior. Record review of the resident's MDS dated [DATE], showed: -The resident's BIMs was 15 out of 15 showing he/she had no cognitive incapacities. -The resident had no mood, behaviors or psychosis/delirium. -The resident needed extensive assistance with transfers and physical assistance with bathing needed, but no assistance noted with dressing grooming eating. -The resident was always incontinent. -The resident had no infections during the lookback period. -The resident was not taking any antibiotics during the lookback period. Record review of the resident's Nursing Notes showed: -9/14/20-at 8:15 A.M., the resident was outside on a smoking break and told other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure to documentation and monitoring for ongoing hospice care (a type of health care that focuses on comfort care of a terminally ill resident) visit and communication with hospice staff and failed to obtain pertinent documentation of the the delivery of hospice care services for one sampled resident (Resident #27) out 19 sampled residents. The facility census was 62 residents. Review of the facility Hospice Services Policy and Procedure revision on 11/17/17 showed: -Hospice services staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available for all interdisciplinary staff to access. -Facility licensed personnel will be responsible to notify hospice service coordinator in event of change of resident condition and prior to transfer to another facility. -All treatment and services are documented in accordance with the facility's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain a safe and sanitary environment in one non-resident room adjacent to a hallway and the Main Dining area by allowing ceiling tiles and walls to become dampened to the point of having a visible black substance appearing to be mold growth on them. This deficient practice had the potential to affect numerous residents, visitors, and staff who passed through, used, or worked in the two areas nearby. The facility census was 62 residents with a licensed capacity for 120. 1. Observations during the facility Life Safety Code room inspections with the Interim Maintenance Director (IMD) on 1/12/21 at 2:41 P.M. showed the following in the Conference room across from the Main Dining room: -One discolored 2 foot (ft) by 4 ft ceiling tile with numerous black splotches on it was sagging down from the ceiling tile grid. -One discolored ceiling tile with black splotches on it was broken apart in a pile on the floor next to the east wall baseboard. -Large black streaks and stains were on the wall above the baseboard on both sides of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.